Sleep endoscopy findings in children with persistent obstructive sleep apnea after adenotonsillectomy

Lingual Tonsillectomy as Part of a DISE-Directed Multilevel Upper Airway Surgery to Treat Complex Pediatric OSA: A Safe and Appropriate Procedure

OBJECTIVE

To study the efficiency of lingual tonsillectomy (LT) as part of multilevel surgery in children with complex obstructive sleep apnea (OSA). To evaluate the safety and the outcomes of LT.

STUDY DESIGN

Retrospective case series.

SETTING

Pediatric tertiary care academic center.

METHODS

We included all children operated for LT to treat complex OSA, from January 2018 to June 2022. All patients underwent a protocolized drug-induced sleep endoscopy (DISE) followed by a coblation LT, associated with the treatment of all other obstructive sites. Patient demographics, medical history, surgery, and outcomes were reviewed. The efficiency of LT was analyzed exclusively in patients with a preoperative and postoperative sleep study.

RESULTS

One hundred twenty-three patients were included. Median age was 8 years (interquartile range, IQR [3-12]). Sixty-five (53%) patients had Down syndrome, 22 (18%) had a craniofacial malformation, and 8 (7%) were obese. LT was associated with adenoidectomy (n = 78, 63%), partial tonsillectomy (n = 70, 57%), inferior turbinoplasty/turbinectomy (n = 59, 48%), epiglottoplasty (n = 92, 75%), and/or expansion pharyngoplasty (n = 2, 2%). Eighty-nine patients underwent a sleep study before and after surgery. The median apnea-hypopnea index (AHI) decreased from 18 events/h (IQR [9-36]) before surgery to 3 events/h (IQR [1-5]) after surgery (P < .001) (patients with a postoperative AHI <1.5 events/h, n = 31, 35%, and an AHI <5 events/h, n = 32, 36%). Seventeen out of 30 (57%) patients could be weaned from continuous positive airway pressure after surgery. Two patients had a postoperative hemorrhage and 2 patients required a transient postoperative reintubation.

CONCLUSION

In children with complex OSA, LT as part of a DISE-directed multilevel upper airway surgery, was a very efficient and safe procedure.

High Prevalence of Obstructive Sleep-Disordered Breathing in Pediatric Patients With Turner Syndrome

OBJECTIVE

Girls with Turner syndrome (TS) often have features that have been associated with obstructive sleep-disordered breathing (oSDB). However, little is known about oSDB in TS. Herein, we aimed to characterize oSDB in young patients with TS and identify associated risk factors.

STUDY DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary care pediatric hospital.

METHODS

We reviewed medical records for patients diagnosed with TS seen at our institution between October 1, 2007 and December 31, 2019 with the first outpatient visit before age 6 years. The prevalence of oSDB was compared to the general pediatric population with 1-sample binomial proportion tests. Clinical characteristics were compared between those diagnosed with oSDB and those without oSDB, and risk factors for oSDB were identified.

RESULTS

Of 151 patients with TS, 73 (48%) were diagnosed with oSDB which is 4-fold higher than the general pediatric population (12%, P < 0.0001). In the multivariable model, adenoid, tonsillar, and inferior turbinate hypertrophy, birthweight, failure to thrive, and older age at the last clinic visit were all associated with increased odds for oSDB.

CONCLUSION

Young children with TS have a high prevalence of oSDB and thus should be screened for oSDB. Polysomnography should be performed in those with associated risk factors and symptoms oSDB. Treatment of oSDB is imperative as individuals with TS are already at increased risk of behavioral problems, neurocognitive deficits, and growth impairment that may be worsened with oSDB.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea

STUDY OBJECTIVES

Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery.

METHODS

A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes.

RESULTS

A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005).

CONCLUSIONS

This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%).

CITATION

Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Development and validation of the international pediatric sleep endoscopy scale (IPSES)

OBJECTIVES

To develop and validate a consensus international pediatric sleep endoscopy scale (IPSES) for pediatric drug-induced sleep endoscopy (DISE).

METHODS

Existing published DISE ratings scales were reviewed in order to develop a consensus rating scale synthesizing the most common features and adding new elements to address areas of controversy. Samples of 30 de-identified DISE video recordings were reviewed to develop and refine the scale. After the consensus scale was defined, a separate sample of 25 de-identified DISE videos were scored with the new consensus scale by the development group and a panel of independent raters. A weighted kappa statistic was used to quantify the inter-rater and intra-rater reliability of the consensus scale at each anatomic level.

RESULTS

Among all raters, intra-rater reliability was most variable for the nasal airway (kappa range 0.33-0.94) and best for the lateral oropharynx (kappa range 0.68-0.95). Inter-rater reliability ranged from 0.43 for the nasal airway to 0.57 at the soft palate.

CONCLUSION

The IPSES is a reliable consensus scale that reflects the most common features of existing scales and can be adopted as a universal scoring scale for pediatric DISE.

International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE)

OBJECTIVES

To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea.

METHODS

The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus.

RESULTS

A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids.

CONCLUSION

This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.

Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea

OBJECTIVE

Drug-induced sleep endoscopy-directed lingual tonsillectomy and midline posterior glossectomy have been employed for the treatment of obstructive sleep apnea in children. The purpose of this study is to evaluate outcomes in children undergoing lingual tonsillectomy, midline posterior glossectomy, or combined base of tongue reduction procedures for obstructive sleep apnea.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care academic medical center.

METHODS

A case series was performed with chart review of pediatric patients with obstructive sleep apnea who underwent base of tongue surgery as directed by drug-induced sleep endoscopy. Pre- and postoperative obstructive apnea-hypopnea index (oAHI) was compared. Age, sex, body mass index z score, and medical history were also evaluated.

RESULTS

A total of 168 children were included, with a mean ± SD age of 8.3 ± 3.6 years. Of these patients, 101 underwent lingual tonsillectomy alone; 25, midline posterior glossectomy alone; and 42, both. Their mean oAHI improvement was 3.52 ± 8.39, 2.55 ± 5.59, and 3.70 ± 6.07, respectively. Each surgical group experienced significant improvement in sleep apnea when pre- and postoperative oAHI was compared (P < .01). Overall surgical success, as defined by oAHI <1 (or <5 without clinical symptoms), was 75% (126 patients).

CONCLUSION

When guided by drug-induced sleep endoscopy, pediatric tongue base surgery can significantly improve oAHI and thus demonstrates promising success in treating pediatric obstructive sleep apnea.

Persistent obstructive sleep apnoea in children: treatment options and management considerations

Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.

Reliability of a pediatric sleep endoscopy scoring system

INTRODUCTION

The surgical management of Obstructive Sleep Apnea (OSA) may be guided by Drug Induced Sleep Endoscopy (DISE), but there is no universally accepted scoring system for DISE in children. The purpose of this study is to compare a novel system to the more commonly used VOTE (Velum, Oropharynx, Tongue base, Epiglottis) system.

METHODS

A total of thirty pediatric DISE videos were reviewed and scored twice by 5 raters with a range of experience levels. The videos were scored using both the VOTE and the new scoring systems. The raters were also asked to recommend surgical intervention based on the DISE exam alone. Intra-rater test-retest analysis of the responses was conducted using weighted kappa (WK) statistic and percentage agreement (PA), respectively. Inter-rater reliability analysis of responses was evaluated using Krippendorff's alpha reliability coefficient (KA). Using a proportional odds model, a comparison of the weighted kappa statistic for the VOTE and the novel scoring systems was conducted.

RESULTS

For the novel scoring system, the intra-rater test-retest WK coefficient was 0.62 and 0.87 and the PA was 64% and 82% at the 25th and 75th percentiles, respectively. For the VOTE system, the intra-rater test-retest WK coefficient was 0.50 and 1.00 and PA was 75% and 100% at the 25th and 75th percentiles, respectively. KA was 0.36 and 0.77 at the 25th and 75th percentiles. In addition, responses to the surgical intervention survey analysis yielded a test-retest WK coefficient of 0.40 and 1.00 and a PA 71%-100% at the 25th and 75th percentiles, respectively. KA was 0.40 and 0.61 at the 25th and 75th percentiles, respectively. There was no significant difference between the 2 scoring systems on the WK statistic (p = .15), but significant difference on PA (p = .01).

CONCLUSION

Our novel scoring system demonstrated intra-rater test-retest and inter-rater reliability similar to the VOTE system, includes more sites of potential airway obstruction, and has potential for widespread use.

Pediatric Obstructive Sleep Apnea: Update for the Primary Care Provider

Pediatric obstructive sleep apnea (OSA) is a common entity that can cause both daytime and nighttime issues. Children with symptoms should be screened for OSA. If possible, polysomnography should be performed to evaluate symptomatic children. Depending on the severity, first-line options for treatment of pediatric OSA may include observation, weight loss, medication, or surgery. Even after adenotonsillectomy, about 20% of children will have persistent OSA. Sleep endoscopy and cine MRI are tools that may be used to identify sites of obstruction, which in turn can help in the selection of site-specific treatment.

Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations

OBJECTIVE

No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database.

METHODS

Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed.

RESULTS

A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index (P = .015, OR = 0.96), structural CNS abnormality (P = .034, OR = 1.95), preoperative oxygen supplementation (P = .043, OR = 1.28), operative time (P = .019, OR = 1.84, 95% CI = 1.28-2.54), and concurrent procedure (P < .001, OR = 2.21) were all independently associated with LOS. Postoperative complications had no significantly associated variables, with an overall low incidence of readmission (5.0%), reoperation (1.7%), and reintubation (1.1%).

CONCLUSION

In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

Sleep Endoscopy Findings in Children With Obstructive Sleep Apnea and Small Tonsils

OBJECTIVE

Obstructive Sleep Apnea (OSA) in children is treated primarily with adenotonsillectomy (AT). When clinical exam demonstrates small tonsils, the success of AT in resolving OSA is uncertain. The purpose of this study is to determine the utility of Drug induced Sleep Endoscopy (DISE) for children with OSA and small tonsils (Brodsky scale 1+) and to identify what obstructive trends exist in this subset of patients and to determine the utility of DISE-directed surgical intervention in patients with small tonsils.

METHODS

A retrospective chart review was performed for patients who underwent DISE at a tertiary care center over a 2-year period. Inclusion criteria were 1+ tonsils and a positive sleep study. Data collected included DISE findings, BMI, comorbid conditions, and pre-op PSG data.

RESULTS

Forty children were included with a mean age of 5.0 years (range 8 months-16 years). Mean preoperative AHI was 5.46 and mean oxygen saturation nadir was 87.1%. The most common contributor to airway obstruction was the adenoid (29 patients, 72.5%), followed by the tongue base or lingual tonsil (21 patients, 52.5%). The palatine tonsils (10 patients, 25.0%), epiglottis (10.0%), or obstruction intrinsic to the larynx (10.0%) were significantly less frequently identified as contributors to OSA when compared to the adenoid (P < .001). The majority of patients had multilevel obstruction (25 patients, 62.5%). Adenoidectomy (27 patients, 67.5%) was the most commonly performed procedure, followed by tonsillectomy (10 patients, 25.0%, P < .001) and tongue base surgery (9 patient 22.5%, P < .001).

CONCLUSION

In this group, small palatine tonsils were infrequently identified as a contributor to airway obstruction and tonsillectomy was avoided in most cases. This study illustrates the utility of DISE as a tool to personalize the surgical management of pediatric patients with OSA and small tonsils on physical exam.

Expert Consensus Statement: Pediatric Drug-Induced Sleep Endoscopy

OBJECTIVE

To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep.

METHODS

Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized.

RESULTS

The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research.

CONCLUSION

Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist

Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.

Outcomes of OSA in surgically naïve young children with and without DISE identified laryngomalacia

INTRODUCTION

Obstructive sleep apnea (OSA) in young children is caused by upper airway obstruction and is associated with changes in cognitive development, temperament and behavior. Adenotonsillectomy (AT) is often utilized as first line therapy for pediatric OSA. Children with laryngomalacia (LM) have a high chance of residual OSA after AT. There is paucity of literature regarding surgically naïve young children with OSA and laryngomalacia. Our study aimed to compare demographics, comorbidities and outcomes associated with OSA in surgically naïve young children with and without laryngomalacia.

METHODS

Retrospective chart review of surgically naïve young children (<2-year-old) with polysomnogram (PSG) diagnosed OSA. All young children underwent pre-operative PSG followed by drug-induced sleep endoscopy (DISE) directed intervention. Variables documented included demographics, comorbidities, history of adenotonsillectomy, DISE directed surgical interventions and pre and post PSG findings. Laryngomalacia was defined as presence of obstruction (Chan Parikh score ≥ 2) at the supraglottic level on DISE evaluation. Demographics and prevalence of comorbidities of those with and without LM were compared using t-test (continuous) and Chi Square (categorical). P value is significant for <0.05.

RESULTS

79 surgically naïve young children with PSG diagnosed OSA performed between 2015 and 2019 were included in the study. Children with LM were younger in age (11 months) and had a higher OSA-18 score (35) compared to children without LM (17 months) (OSA-18 score: 5). No significant difference was noted in the pre-DISE PSG parameters in the 2 groups. 56.1% of children with OSA and laryngomalacia did not need AT. Both children with and without laryngomalacia showed improvement in AHI on post-DISE PSG. Higher baseline AHI was associated with greater improvement in AHI.

CONCLUSION

Surgically naïve young children with OSA and LM present earlier than those without LM and report a significantly worse quality of life Young children with a higher baseline AHI were found to have greater improvement in severity of OSA post-DISE and surgical intervention. Majority of children with OSA and laryngomalacia did not need adenotonsillectomy after a preprocedural DISE assessment yet showed similar improvement in AHI. More studies are needed to determine which patients with OSA and laryngomalacia will need multilevel interventions.

Propofol versus dexmedetomidine during drug-induced sleep endoscopy (DISE) for pediatric obstructive sleep apnea

PURPOSE

To test for differences in DISE findings in children sedated with propofol versus dexmedetomidine. We hypothesized that the frequency of ≥ 50% obstruction would be higher for the propofol than dexmedetomidine group at the dynamic levels of the airway (velum, lateral walls, tongue base, and supraglottis) but not at the more static adenoid level.

METHODS

A single-center retrospective review was performed on children age 1-18 years with a diagnosis of sleep disordered breathing or obstructive sleep apnea (OSA) who underwent DISE from July 2014 to Feb 2019 scored by the Chan-Parikh scale sedated with either propofol or dexmedetomidine (with or without ketamine). Logistic regression was used to test for a difference in the odds of ≥ 50% obstruction (Chan-Parikh score ≥ 2) at each airway level with the use of dexmedetomidine vs. propofol, adjusted for age, sex, previous tonsillectomy, surgeon, positional OSA, and ketamine co-administration.

RESULTS

Of 117 subjects, 57% were sedated with propofol and 43% with dexmedetomidine. Subjects were 60% male, 66% Caucasian, 31% obese, 38% syndromic, and on average 6.5 years old. Thirty-three percent had severe OSA and 41% had previous tonsillectomy. There was no statistically significant difference in the odds of ≥ 50% obstruction between the two anesthetic groups at any level of the airway with or without adjustment for potential confounders.

CONCLUSION

We did not find a significant difference in the degree of upper airway obstruction on DISE in children sedated with propofol versus dexmedetomidine. Prospective, randomized studies would be an important next step to confirm these findings.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

Drug-Induced Sleep Endoscopy in Pediatric Obstructive Sleep Apnea

OBJECTIVE

To describe drug-induced sleep endoscopy (DISE) findings in children with obstructive sleep apnea and to differentiate them between surgically naïve children and children who had adenotonsillectomy performed.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Secondary care hospital.

SUBJECTS AND METHODS

A cohort of 56 children with the diagnosis of obstructive sleep apnea was submitted to DISE and subsequent upper airway surgery: 23 were surgically naïve, and 33 had persistent obstructive sleep apnea after adenotonsillectomy. Comparisons between groups were calculated with chi-square test and Student's t test. Simple linear regression was used to model polysomnographic indices.

RESULTS

In surgically naïve children, the most common sites of obstruction were the adenoids (78.2%) and the lateral pharyngeal walls/tonsils (82.6%). In children with persistent obstructive sleep apnea after adenotonsillectomy, the most common sites of obstruction were the adenoids (54.5%), followed by the supraglottis (48.5%) and the tongue base (45.5%). No correlation was found between obstructive apnea-hypopnea index and DISE findings. Simple linear regression revealed that the degree of obstruction at the tongue base (β = -0.73; 95% CI, -1.22 to -0.25; P = .004) and the presence of multilevel obstruction (β = -1.75; 95% CI, -3.20 to -0.30; P = .02) predicted saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy.

CONCLUSION

DISE findings differed between surgically naïve children and children with persistent obstructive sleep apnea after adenotonsillectomy. Increased obstruction at the level of the tongue base and the presence of multilevel obstruction predicted a lower saturation nadir in children with persistent obstructive sleep apnea after adenotonsillectomy.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

Pediatric Drug Induced Sleep Endoscopy: A Simple Sedation Recipe

Objective:

To describe a minimalist approach to sedating children for DISE procedures.

Methods:

We searched existing literature and derived and tested our algorithm on patients using evidence-based studies.

Results:

We were able to successfully sedate, without airway intervention, 15 highly complex children with a variety of comorbidities for DISE procedures.

Conclusion:

We describe a minimalistic sedation approach for DISE procedures in highly complex children. Further studies are required to compare this regimen to natural sleep states.

Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

Objective

To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data.

Data Sources

PubMed/MEDLINE and 4 additional databases.

Review Methods

Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre).

Results

After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of −2.7 events/h; 95% confidence interval [CI], –5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of −4.2 events/h; 95% CI, –6.3 to −2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1).

Conclusions

Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

OBJECTIVES

For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.

RESULTS

We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.

CONCLUSIONS

We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.